Informed consent and ethical issues pertaining to female sterilization-scoping review

Abstract

BACKGROUND : Female sterilization, a safe, permanent method of contraception that blocks the fallopian tubes, has been in use since the 19th century. The procedure necessitates informed consent, a critical step that has been marred by reports of forced sterilization since World War II. These incidents often stem from inadequate consent processes where ethical principles are overlooked or deliberately flouted. The persistent issue of forced sterilization, primarily attributable to a flawed informed consent process, highlights significant ethical concerns. OBJECTIVES : This scoping review aimed to identify the ethical challenges associated with the informed consent process for female sterilization, including instances of forced sterilization. SEARCH STRATEGY : The review employed a comprehensive electronic search across multiple databases, including PubMed, Scopus, Web of Science, Google Scholar, and ProQuest Central, targeting literature published in English between January 2000 and December 2021. The search strategy utilized key terms related to informed consent, ethical issues, and female sterilization, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) methodology for database search and screening. SELECTION CRITERIA : The search resulted in the inclusion of 55 published articles for this review. Studies were selected if they focused on informed consent for female sterilization and reported on forced or coerced sterilization involving mentally competent women aged 18 years and older. Exclusions were made for studies on women younger than 18 years, those related to emergency procedures, and non–English language publications. DATA COLLECTION AND ANALYSIS : A two-stage screening process was used to assess the relevance of the identified studies, with independent reviewers evaluating titles, abstracts, and full texts. Data were extracted using a predefined tool, and discrepancies were resolved through discussion. The analysis focused on summarizing the ethical issues identified and recommendations for improving the consent process. MAIN RESULTS : The review identified vulnerable populations, particularly women reliant on the state or government for health care, as being at higher risk of forced sterilization. Cases of sterilization without consent, under coercion, sedation, or through inducements/incentives have been reported. Recommendations from international obstetrics and gynecology societies, health organizations, human rights bodies, and local governments have been issued in an attempt to improve the consent process. Notably, the United States implemented a Medicaid consent form in the 1970s, which has yet to be revised, attracting significant criticism for some of its components. Meanwhile, low- and middle-income countries lack standardized tools to address complaints related to this issue. CONCLUSION : This review identifies persistent ethical challenges in the informed consent process for female sterilization globally, with forced sterilization disproportionately affecting vulnerable populations. The review underscores the urgent need for the development and implementation of standardized consent tools, with ongoing review, to protect women's autonomy and prevent unethical practices, especially in low- and middle-income countries.